Provider First Line Business Practice Location Address:
3740 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-917-3011
Provider Business Practice Location Address Fax Number:
812-238-3040
Provider Enumeration Date:
06/20/2012